Review
The impact of substitution treatment in prisons—A literature review

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Abstract

Substitution treatment (ST) has established itself as a generally recognised type of treatment for opioid dependence worldwide. Although the number of countries providing ST in prison has slowly started to grow over the last years, its application in the custody setting remains controversial. ST in prison is mainly employed in form of detoxification. Maintenance treatment is provided in only a limited number of international prisons.

This literature review is centred around the question: “What is known about the effectiveness of prison based ST?” Furthermore, it investigates how this knowledge can be applied to improve treatment scope and quality. Effectiveness, as defined by the examined studies, refers to short- and long-term reduction of drug use and relapse, reduction in drug use related risk behaviours, reduction in criminal conduct and recidivism, facilitating the manageability of drug using prisoners and improving their physical stabilisation. In this context, substitute dosage, treatment duration, patient retention rates, complementary psycho-social care and the effects of disrupting maintenance treatment when entering the institution are scrutinised.

Results show that prison-based ST and especially prison-based methadone maintenance treatment (PMMT) can reduce drug use and injection in penal institutions. Moreover, PMMT provision can reduce injecting risk behaviours as well as drugs charges and re-admission rates. However, for PMMT to retain patients in treatment and reduce illegal drug use and criminal behaviour a sufficiently high dose of methadone (e.g., >60 mg) and the treatment duration lasting the entire period of imprisonment appear crucial.

On the basis of the analysed results the authors recommend the provision of PMMT for individuals with long-standing opioid dependence and suggest major expansions of prison based ST in many countries.

Introduction

Substitution treatment (ST) in its different forms has established itself as a widely accepted harm reduction and treatment measure for opioid dependent individuals in the community in many countries (Council of Europe, 2001). The effectiveness of methadone maintenance treatment (MMT) is now widely acknowledged (e.g., Farrell, Gowing, Marsden, Ling, & Ali, 2005; Gerstein & Harwood, 1990). Effectiveness refers to a reduction or cessation of opiate use (Ball & Ross, 1991; Condelli & Dunteman, 1993; Hubbard, Rachal, & Craddock, 1984; Sees et al., 2000; Strain, Bigelow, Liebson, & Stitzer, 1999; Vanichseni, Wongsuwan, Choopanya, & Wongpanich, 1991), reduced HIV risk behaviours, especially needle use (Sorensen & Copeland, 2000) and consequently reduced HIV and viral hepatitis transmission rates (Hartel & Schoenbaum, 1998; Metzger, Navaline, & Woody, 1993; Zangerle et al., 1992; Novick, Joseph, & Croxson, 1990) as well as a decrease in criminal involvement and redundancy. In a common position paper UNAIDS/WHO/UNODC (2004, p. 2) state “Substitution maintenance therapy is one of the most effective treatment options for opioid dependence. It can decrease the high cost of opioid dependence to individuals, their families and society at large by reducing heroin use, associated deaths, HIV risk behaviours and criminal activity. Substitution maintenance therapy is a critical component of community-based approaches in the management of opioid dependence and the prevention of HIV infection among injecting drug users (IDUs).”

However, empirical research on the effectiveness of treatment programmes for drug dependency in the penitentiary system in general and of ST in particular is hitherto rather limited and incomplete (e.g. Pearson & Lipton, 1999). Most scientific work on ST in prison has been carried out in the United States and Australia with only a restricted number of studies conducted in Europe, Canada or other countries, such as Iran (Jürgens, 2006; Kerr & Jürgens, 2004). The majority of studies has focussed on methadone. Relatively lately authorised substitution substances such as buprenorphine, slow release morphine or even medical heroin have only recently been studied to rather restricted degrees (WHO, 2005).

Looking at substitute prescribing in the setting of penal institutions all treatment aspects present themselves as subject to controversial discussion. Comparing the prescribing practice in prison to the practice in the community the philosophies and thus formulated goals tend to diverge: As opposed to community drugs services prisons primarily aim at providing safety and rehabilitation and only secondly at health improvement. Consequently, general abstinence rather than harm reduction orientation is pursued, different values and characteristics are associated with substitution drugs (e.g., perception of methadone as an illegal “street drug” rather than a therapeutic medicament), security aspects have to be acknowledged (e.g., supervision of intake to avoid diversion of the medication (cf. Magura, Rosenblum, Lewis, & Joseph, 1993)), and the difference in the doctor–patient relationship (e.g., no free choice of doctor) has to be recognised. Moreover, structural conditions of the prison setting as such have to be considered (e.g., dependent on the spatial capacities of the institution the confrontation with the prison drugs scene can be increased). Whereas opiate users in the community often have easy access to methadone over the course of their drug using career, when entering prison either an automatic detoxification or a voluntary decision to interrupt drug use are common.

Arguments against prison-based ST by professionals, prison health authorities and politicians sometimes show inconsistencies. The argument, for example, that overall injection rates decline in prison for various reasons (voluntary decision, limited availability of drugs, etc.), is put into perspective by scientific evidence demonstrating that the remaining injection incidence tends to be of highly risky nature (cf. Shewan, Gemmel, & Davies, 1994). While in many cases prisoners discontinue or significantly reduce their drug use when entering the institution, others continue their use more riskily or might even start inhaling or injecting opiates (Allwright et al., 2000; Lines & Stöver, 2005; Shewan, Stöver, & Dolan, 2005; Wood et al., 2006).

The controversial debate around prison ST is further fuelled by the fact that opioid dependent individuals frequently alternate between being patients at one and prisoners at another time. While in the community they might be treated as patients and receive ST, in the correctional setting they are primarily treated like prisoners, who should avoid illegal behaviours, such as drug use, which again often tends to be the reason for their incarceration in the first place. The aim of prisons to enable prisoners to lead a life without committing criminal offences therefore tends to rely on an abstinence-oriented approach.

The acknowledgement of the possibility to transfer the positive experiences with ST in the community to the prison setting grows rather slowly. Yet, those prison health services recognising this possibility and in particular the benefits of ‘throughcare’, that is, avoiding a treatment interruption through detoxification, are still a clear minority worldwide. However, more and more prison doctors are beginning to prescribe substitution drugs, not at last as a result of the increasing numbers of patients in the community (e.g. 550,000 ST patients in the 25 EU member States (EMCDDA, 2005)). Countries now providing ST in prison to different degrees embrace the majority of EU member states, Australia, New Zealand, some American states and some central Asian countries. These changes can be regarded as a development towards the ‘principle of equivalence’ referring to the offer of medical care in the community and in prison demanded by a number of organisations, such as the WHO (WHO, 1993). Still, from the prison management point of view drug using prisoners, including prisoners in substitution therapy, are still often seen as ‘security risk’. Although the medical services in many countries are organised separately and independently, controversies arise with respect to the daily routines (e.g. regarding breach of confidentiality).

This literature review examines the impact of substitution treatment in the prison setting while particularly focussing on a number fundamental issues, such as how the existing knowledge on ST in prison can be used as a baseline for adjusting the scope and quality of this treatment form in this specific location. Furthermore, it investigates substitution medications in terms of dosage, treatment duration, complementary psycho-social care and retention rates concerning imprisoned patients. The impact of ST on the reduction of drug related risk behaviours (e.g., sharing of injecting equipment) in penal institutions is looked at as well as the effects of disrupting maintenance treatment on prison entry. Besides, practical problems arising on an everyday basis concerning the provision of substitution drugs in the institution and the impact of ST on the prison atmosphere (also regarding the commitment of crime) are considered. Amongst those fundamental points are also the long-term effects of ST on release outcome.

Section snippets

Literature review

An extensive, systematic literature review of studies relevant to the above described research concerns has been carried out, which involved the utilisation of a wide range of computerised and printed sources, such as databases (e.g., Medline, PsycFIRST), the world wide web, online and conventional libraries and archives (e.g., International Centre for Prison Studies/King's College/UK, ARCHIDO/BISDRO/Germany) and personal contacts to researchers, and other experts in the field of prison-based

Conclusions

Existing research concerned with the effectiveness of prison-based ST has primarily been concerned with PMMT and shows that this treatment form can reduce heroin use and drug injection in penal institutions. Other forms of prison-based ST have not yet been studied sufficiently to draw clear conclusions. For PMMT to be effective in contributing to health and social stabilisation a sufficiently high methadone dose (at least 60 mg have been suggested) and the prescription lasting the entire period

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      She considered the control and supervision in the OMT programme offensive and was not surprised to see buprenorphine diversion flourishing in the prison. The available literature reports a low prevalence of methadone and buprenorphine diversion from prison-based OMT programmes (Kinlock, Gordon, Schwartz, & Fitzgerald, 2010; Magura et al., 2009) and documents that OMT reduces participants’ in-prison drug use, risk-taking behaviour and other subcultural involvement during confinement (see Stallwitz & Stöver, 2007; Stöver & Michels, 2010, p. 3 for reviews). The ethnographic analysis presented above, however, reports a different finding: diversion of buprenorphine from the prison-based OMT programme was extensive and contributed to a vibrant drug subculture in the prison, in which a substantial number of prisoners were involved in the use and distribution of prescription opioids (see also Mjåland, 2014).

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